What are the responsibilities and job description for the Associate Director, Healthcare Operations (Hybrid) position at Navitus Health Solutions, LLC?
Company: Archimedes Rx About Us: Archimedes Rx - Transforming the Specialty Drug Benefit - Archimedes is the industry leader in specialty drug management solutions. Founded with the goal of transforming the PBM industry to provide the necessary ingredients for the sustainability of the prescription drug benefit – alignment, value and transparency – Archimedes achieves superior results for clients by eliminating tightly held PBM conflicts of interest including drug spread, rebate retention and pharmacy ownership and delivering the most rigorous clinical management at the lowest net cost. Pay Range: USD $0.00 - USD $0.00 /Yr. Work Schedule Description (e.g. M-F 8am to 5pm): Standard business hours Overview:
The Associate Director – Operations will be responsible for managing the ongoing operations team for claims, eligibility and accumulators as well as implement new benefit plan setups for commercial clients. Job responsibilities include reviewing client benefit requests, identifying and defining their needs and requirements, determining best operational approach, performing setup in the pharmacy claim system, testing benefits and data loads, and documenting each of the above. The position will also perform setup testing and have responsibility for promoting plan benefit designs and/or changes into a production environment. This position will also work on operational issues, analyze, and identify solutions to resolve issues in benefit setup, claims processing, eligibility and accumulators and other potential operational gaps and be expected to identify process improvement opportunities to make benefit plan design setup more efficient. Finally, this position will support daily claim quality assurance by completing QA review processes, metric generation, and overall process improvement.
Responsibilities:
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Location : City: St. Louis Location : State/Province: MO Location : Country: US
Based on our rapid growth, we are expanding our PBM operations team at an exciting time in our history. Archimedes is looking for a person with a passion for helping plan sponsors control the cost of drugs through an aligned business model, value-based coverage, data-driven solutions, and innovative technologies. Given our continued growth trajectory, we are looking for an experienced healthcare operations leader who can grow with the company’s core operations and lead the expanding team in a hybrid role working onsite 3 days per week.
The Associate Director – Operations will be responsible for managing the ongoing operations team for claims, eligibility and accumulators as well as implement new benefit plan setups for commercial clients. Job responsibilities include reviewing client benefit requests, identifying and defining their needs and requirements, determining best operational approach, performing setup in the pharmacy claim system, testing benefits and data loads, and documenting each of the above. The position will also perform setup testing and have responsibility for promoting plan benefit designs and/or changes into a production environment. This position will also work on operational issues, analyze, and identify solutions to resolve issues in benefit setup, claims processing, eligibility and accumulators and other potential operational gaps and be expected to identify process improvement opportunities to make benefit plan design setup more efficient. Finally, this position will support daily claim quality assurance by completing QA review processes, metric generation, and overall process improvement.
- Troubleshoot and performs research on claims adjudication issues or inquiries and liaise with other functional areas on escalated pharmacy claims processing, formulary and benefit issues
- Ensure benefit compliance with federal and state laws
- Assist in creating and maintaining documentation of client plan designs, detailing any custom maintenance processes, and configuration best practices. Includes documentation of adjudication hierarchies, edits, restrictions, tables, carriers, and other configuration components
- Apply pharmacy, formulary, and benefit configuration to effectuate change as specified in new client implementation documentation or submitted change requests.
- Acquires a thorough understanding of pharmacy system logic for claims adjudication, system constraints, and conflicting benefit logic configurations
- Ensure work instructions and training for operations are accurate and thorough
- Responsible for successful file loads to the Claims Adjudication System within specified client performance guarantee timeframes
- Identify root cause, triage and support resolution of all errors within SLA of transferring and loading the files
- Request, validate and confirm full file data feeds from Clients to ensure system integrity through audits and reconciliation
- Proactively manage
- Conduct routine reviews and audits of team members
- Lead meetings to drive operational efficiencies for new or existing processes
- Manage capacity and pipeline planning for team
- Bachelor's degree and a minimum of three (3) years of experience in operations, preferably healthcare with two (2) years of experience in a defined leadership role
- Must be able to work onsite at our St. Louis, MO or Nashville, TN locations a minimum of 3 days in the office.
- 3 years in a similar role in a PBM environment desired
- Experience with pharmacy claims analysis and benefit set up is required
- In-depth drug and PBM Operations knowledge and terminology is desired
- Demonstrated skills in forming and fostering high-performing, cross-functional teams
- Excellent written and oral communication skills, adaptable for all levels of management
- Proficient at identifying root causes of business and/or workflow problems and determining innovative solutions and opportunities
- Ability to organize, prioritize, and manage multiple initiatives with effective and accurate results
- Ability to translate business needs and processes into clear and concise procedural documentation
- A working knowledge of Microsoft Office applications is required. SQL skills are a plus
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